Treatment Protocol
Copyright alophysio (2007) – Developed mainly from Vicenzino, Bill 2003 Lateral Epicondylalgia: A Musculoskeletal Physiotherapy Perspective. Manual
Therapy 8 (2) : 66-79 and various course notes
Subjective Examination Points to Note:
�� Body chart:
�� History:
�� Onset
�� When
�� How
�� What Symptoms:
�� Then
�� Now
�� Risk Factors:
�� Training Error (eg. Technique, fitness, periodisation)
�� Equipment Faults (eg. Recent changes, inappropriate equipment)
�� Biomechanical (eg. Trunk, shoulder girdle, local)
�� Aggravating and Easing Factors:
�� Functional Interference
�� Activity
�� Position
�� Pain Questionnaires:
�� 5 Functional Activities Pain VAS
�� Patient-Rated Elbow Questionnaire (MacDermid 2001)
�� American Shoulder and Elbow Surgeons – ASES-e)
Objective Examination Points to Note:
�� Observation:
�� Habitual movement patterns or postures
�� Carrying angle
�� Muscle Bulk / Atrophy / Hypertrophy / Swelling
�� Functional Activity Evaluation (Commonly involves gripping)
�� Motion: Active and Passive (F, E, Sup, Pron, CM ± WB/Distraction)
�� PAMs:
�� Positional Fault
�� Movement Impairment
�� Reactivity
�� Muscle Tests:
�� Stress Test:
�� Stability (eg. Varus, valgus, PLRI)
�� Diagnostic Specific
�� Condition Specific
�� MWM
General Treatment Goals
�� Restore Muscle Function
�� Early and Substantial Pain Relief
�� Manual Therapy
�� Tape
�� Self-Treatment

�� Endurance Base First
�� Strength Second
�� Restore Motor Function (Functional Basis)
Early and Substantial Pain Relief
Manual Therapy
�� x6-10 reps provided substantial pain relief and no latent pain
�� Apply glide, patient either grips or moves elbow, release glide
�� If Pain-Free Grip (PFG) Strength Deficit predominates over (Or Equal To) Pressure Pain Threshold (PPT):
Step One:
�� Painful Grip:
�� Elbow SLGWPFG ± Belt (Sustained Lateral Glide With Pain-Free Grip)
�� Painful Movement:
�� Elbow SLGWM ± Belt (Sustained Lateral Glide With Movement)
Step Two (If Step One Not Effective):
�� Radio-Humeral Joint SPAWPFG (Sustained PA-glide With Pain-Free Grip)
Step Three (If Step One and Two Not Effective):
�� HVTRHJ (High Velocity Thrust to the Radio-Humeral Joint)
�� If Pressure Pain Threshold (PPT) predominates over Pain-Free Grip (PFG) Strength Deficit:
Step One:
�� Evaluate C/S and Upper Quadrant Neural Structures and Treat Abnormal Findings
�� Elvey’s Lateral Glide of the C/S (C5/6/7)
�� C/S or T/S STWULM (Sustained Transverse-pressure With Upper Limb Movement)
Taping
�� Painful Grip:
�� Tape For Elbow SLGWPFG Manual Technique
�� Tape to be applied with SLGWPFG
�� Tape from medial to lateral, inferior to superior across cubital fossa
�� Painful Movement:
�� Tape For Elbow SLGWM Manual Technique
�� Tape in Elbow Flexion if Extension painful
�� Tape in Elbow Extension if Flexion painful
�� Tape to be applied with SLGWPFG
�� Tape from medial to lateral, inferior to superior across cubital fossa
�� Tape For Radio-Humeral Joint SPAWPFG Manual Technique
�� Tape to be applied with SLGWM
�� Tape #1 from lateral to medial, posterior to anterior around radial head to anterior aspect of ulna
�� Tape #2 from lateral to medial, posterior to anterior across cubital fossa to posterior aspect of humerus
�� Diamond Tape of the Elbow
�� For lateral elbow pain present most of the time
�� Particularly useful for resting pain or pain at night
�� All tape to be from inferior to superior in direction
�� Tape #1 and #2 from common lateral aspect of the forearm to anterior and posterior joint-line of elbow
�� Tape #3 and #4 from anterior and posterior joint-line to common lateral aspect of the humerus
Self-treatment
�� x6-10 reps provided substantial pain relief and no latent pain
�� Patient applies glide, either grips or moves elbow, release glide

�� Painful Grip:
�� Elbow SLGWPFG ± Belt (Sustained Lateral Glide With Pain-Free Grip)
�� Patient to apply lateral glide to forearm while blocking humerus with belt or against a doorjamb or corner of wall then produce a pain-free grip
�� Painful Movement:
�� Elbow SLGWM ± Belt (Sustained Lateral Glide With Movement)
�� Patient to apply lateral glide to forearm while blocking humerus with belt or against a doorjamb or corner of wall then produce a pain-free movement
�� Radio-Humeral Joint SPAWPFG (Sustained PA-glide With Pain-Free Grip)
�� Patient to apply PA glide to R-H Joint then produce a pain-free grip
Exercise Programme:
Stage 1: Endurance Base
Stage 1a: For most patients…
�� Load = x12-15 Repetition Max (RM)
�� x8secs (4secs up/ 4secs down)/rep
�� x12-15 reps/set
�� x1-2mins rest between sets
�� x3 sets/session
�� x1 session/day
�� Progress to Stage2
Stage1b: For deconditioned patients with DOMS after doing Stage 1a…
�� Load = x12-15 Repetition Max (RM)
�� x8secs (4secs up/ 4secs down)/rep
�� x12-15 reps/set
�� x1-2mins rest between sets
�� x1 set/session
�� x2 sessions/day
�� Progress to Stage 1a
Stage 2: Strength Base
�� Load = x6-8 Repetition Max (RM)
�� x8secs (4secs up/ 4secs down)/rep
�� x6-8 reps/set
�� x1-2mins rest between sets
�� x3 sets/session
�� x1 session/day
�� Progress to Stage 3
Stage 3: Restore Motor Function (Functional Basis)
�� The exercise to be done are functional tasks
�� Load = x6-8 Repetition Max (RM)
�� x6-8 reps/set
�� x1-2mins rest between sets
�� x3 sets/session
�� x1 session/day
�� Progress to heavier and harder tasks
Exercises:
Load Type:
Core Set of Exercises:
Other UL Exercises:
�� Isometric
�� Wrist F
�� Tricep Extensions

�� Eccentric Only
�� Wrist E
�� Bicep Curls
�� Theraband
�� Wrist RD
�� Chest Press
�� Free Weights
�� Wrist UD
�� Shoulder Press
�� Theraband Flexbar
�� Wrist Supn
�� Bent-Over Rowing
�� Wrist Pron
�� Scapula Retractions
�� Gripping (With Theraputty/Grip Dynamometer / Eggsercis

Patient Information Sheet:
�� Most “Tennis Elbow” problems are treatable using physiotherapy.
�� Your physiotherapist will use:
�� “Hands-on” manual techniques
�� Taping
�� Teach you how to treat and tape yourself at home
�� Teach you how to do exercises and stretches at home to help your arm strength
�� Research has proven that this system we use IS EFFECTIVE.
�� Your physiotherapist will need to see you for 2-3 sessions for the first week
�� This is to:
�� Assess and begin manual therapy and exercises
�� Teach you how to treat and tape yourself at home
�� Teach you how to do exercises and stretches at home to help your arm strength
�� Your physiotherapist will then need to see you for 1 session every week/fortnight
�� This is to:
�� Review your exercises and self-treatment to make sure you are doing them correctly
�� Progress your exercises and stretches as you get better
�� Make sure you are actually doing your exercises
�� Your physiotherapist will not use:
�� Ultrasound, Laser or any other machines
�� Massage or “frictions”
�� Voltaren or Feldene gel
�� Research has proven that these treatments DO NOT HELP your condition.
�� It is important to understand that during the programme, there should be no pain !
�� Please tell your physiotherapist if you are getting pain during treatment and they will stop.
�� When you do your self-treatment at home, you SHOULD NOT get pain – Stop if you do !
�� When you do your exercises at home, you SHOULD NOT get pain – Stop if you do !
�� It is important to understand that you will feel good during and after your treatment and self-treatment at home but the pain will come back for about 3 weeks.
�� THIS IS NORMAL !!
�� STICK WITH THE PROGRAMME !!
�� Research shows that this programme will be effective in gaining a long-term solution to your pain
�� It is important to follow the exercise programme your physiotherapist gives you.
�� You will see stable strength improvements within 3-6 weeks.
�� You should avoid:
�� Picking up objects with your palm facing down
�� Any activity that aggravates your symptoms
�� You should do:
�� Your exercises
�� Your stretches
�� All activities that do not aggravate your symptoms
Listen to your physiotherapist !!